Endorsing….

 RD
 34 yo
 Female
 Married
 Roman Catholic
 Cebu City
 Chief Complaint
 Epigastric pain
 Past Medical History
 Nonhypertensive
 Nondiabetic
 Nonasthmatic
 No food and drug allergies
 HOSPITALIZATIONS:
• August 2014 PSH Gallstone
• November 2014 PSH Primary low segment
transverse C-section
 History of Present Illness
5 • Onset of epigastric pain

MO •
•
Crushing in character
Radiated to the RUQ and RLQ

S •
•
•
PS 9/10
Aggravated after eating oily and fatty food

PTA
Sought consult with an AP and ultrasound was done
which revealed cholelithiasis and cholecystitis as
stated and was advised surgery but was deferred since
patient was still pregnant at that time
• Given Omeprazole and Ranitidine to be taken as
needed for pain
• Condition tolerated
 History of Present Illness

Night • Condition persisted wherein pain

could not be relieved by
PTA medications
• Now associated with vomiting of
previous ingested food amounting
to 1 cup for 2 episodes, non bloody
• Thus prompted admission
 Family History
 Heredofamilial diseases include hypertension
on both sides
 OB History
 Menarche at 12 years old
 Monthly, regular interval
 Lasting for 3-5 days
 Consuming 2-3 pads per day
 With presence of dysmenorrhea
 LMP: March 2014
 Currently G1P1 (1001)
 Personal and Social History
 Non smoker
 Non alcoholic beverage drinker
 Non illicit drug user
 PHYSICAL EXAMINATION
 General Data:
• Awake, alert, afebrile and NIRD with the ff vital signs:
T= 36.0 PR=97 RR= 20 BP= 120/80
PS= 9/10 Wt = 54kg Ht= 153cm
BMI= 23.06
 SKIN:
• Warm, good turgor and mobility
 HEENT:
• Anicteric sclerae, pink palpebral conjunctiva, no
nasoaural discharge, no lymphadenopathy
 CHEST/LUNGS:
• Equal chest expansion, clear breath sounds
 CARDIOVASCULAR:
• Adynamic precordium, distinct heart sounds
 GIT:
• Flabby, NABS, soft, (+) Murphy’s sign, (+) direct
tenderness epigastric, RUQ, RLQ area, (+) Post-op C-
section scar, transverse, hypogastric area
 GUT:
• (-) KPS, bilaterally
 EXT:
• Strong peripheral pulses, CRT <2secs
 CNS:
• Within normal limits
 Impression
 Calculous Cholecystitis
 Differential Diagnosis
 Peptic ulcer with or without perforation
 Pancreatitis
 Appendicitis
CASE DISCUSSION
Anatomy
 Gallbladder
 Pear-shaped
 7-10 cm
 Average capacity: 30-50 mL
 Location: fossa (inferior surface of the liver)
 4 anatomic areas:
• Fundus
• Body
• Infundibulum
• Neck
 Bile Ducts
 Left and right Hepatic Duct
• Left (longer)
 Common hepatic duct
• Length: 1-4cm
• Diameter: 4mm
 Cystic duct
• Spiral valves of Heister
 Bile Ducts
 Common bile duct
• Length: 7-11 cm
• Diameter: 5-10 mm
• 3 portions:
 Supraduodenal
 Retroduodenal
 Pancreatic
 Ampulla of Vater
 Sphincter of Oddi
• Thick coat of circular
smooth muscle
• 4-6mm
• 13mmhg
• regulates the flow of
bile
• Interstitial cells of
Cajal
Calot’s Triangle
Histology
 Single, highly folded tall columnar epithelium
• Cholesterol and fat globules
 Tubuloalveolar glands
• mucosa
• Secretes mucus
• infundibulum and neck
 Layers:
• Mucosa
• Lamina propria
• Muscle layer
 Circular longitudinal and oblique fibers
• Perimuscular subserosa
 Absent:
• Muscularis mucosa
• submucosa
Physiology
 Liver
• Production of bile
• 500-1000 mL a day
 Bile
 Composition:
• Water, electrolytes, bile salts, proteins, lipids and bile
pigments
• Sodium, potassium, calcium, chlorine
 pH:
• Neutral or slightly alkaline
 Color:
• Bilirubin diglucoronide (pigment)
 Gallbladder Function
 Main function
• Concentration of bile
• Storage of bile
 Absorption and secretion
• Mucosa
 Greatest absorptive power per unit area
• Fasting State:
 80% of bile stored in GB
• Mucus Glycoproteins
 prevents the GB from the lytic action of bile
 facilitate passage of bile thru cystic duct
• Hydrogen Ions (acidification)
 promotes calcium solubility prevents calcium
precipitation
 Motor Activity and Neurohormonal Regulation
• Motilin
 gradual relaxation & emptying
• Vagus nerve
 Contraction = increase secretion
• Splanchnic nerve
 Inhibitory = decrease flow
 Cholecystokinin (CCK)
 Peptide
 Upper GI tract
 Duodenum ( highest concentration)
 Plasma half life: 2 to 3 mins
 Liver and kidneys
 Function:
• Contraction= Emptying
 50-70% (30 to 40 mins)
 Other hormones:
• Vasoactive intestinal polypeptide
• Somatostatin
• Substance P
• Enkephalin
Pathogenesis
 Secondary to gallstones in 90-95% of cases
 In <1% of cases, it is caused by a tumor obstructing the
cystic duct
 Initially an inflammatory process
• Lysolecithin
• Bile salts
• Platelet-activating factor
 In 5-10% of cases, the inflammatory process progresses
and leads to ischemia and necrosis of the gallbladder wall
 Secondary bacterial contamination documented in 15-
30% of patients undergoing cholecystectomy
Clinical Manifestations
 Symptoms
 Biliary colic
• Pain does not subside; unremitting
• May persist for several days
 RUQ or Epigastric pain
• May radiate to the upper part of the back or the
interscapular area
 Fever
 Anorexia
 Nausea and vomiting
 Reluctant to move
 Physical Exam
 Focal tenderness and guarding on the RUQ
 Palpable mass
 Murphy’s sign
 Laboratory Picture
 Mild to moderate leukocytosis
 Mild elevation of serum bilirubin
 Mild elevation of alkaline phosphatase,
transaminases, and amylase
Differential Diagnosis
 Peptic ulcer with or without perforation
 Pancreatitis
 Appendicitis
 Hepatitis
 Pleuritis
Diagnosis
 Ultrasonography
• Most useful radiologic test
• 95% sensitivity and specificity
• Presence or absence of stones
• Thickening of the GB wall
• Pericholecystic fluid
 Biliary Radionuclide Scanning
Treatment
 Laparoscopic cholecystectomy
• Procedure of choice
• 10-15% conversion rate to an open cholecystectomy
 Antibiotics
• 3rd generation cephalosporin
• 2nd generation cephalosporin + metronidazole
Thank you!
Have a nice day!
 Bile Formation
Primary bile salts Conjugation
Cholesterol (liver) • Cholate • Taurine
• Chenodeoxycholate • Glycine

80 % - absorbed

Digestion and Excreted

Dehydroxylated absorption of fats (hepatocytes)
( deconjugated) by
gut bacteria

Secondary bile acids

• Deoxycholate
• lithocholate